Registered Nurse, Clinical Documentation Specialist

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🔥 48 minutes ago

⚔️ Virginia – Remote

⚔️ Virginia – Remote

💵 $67.9k - $135.7k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

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UVA Pipelines & Pathways

WebsiteLinkedInAll Job Openings

10,000+ employees

📚 Education

🎯 Recruiter

Education • Recruitment

UVA Pipelines & Pathways is a University of Virginia careers program focused on helping job seekers access entry-level employment at UVA that does not require advanced education or prior work experience. The program aims to open doors into the university workforce and provide opportunities for upward mobility through targeted hiring pathways (including temporary and wage positions) and resources for applicants looking to join academic, administrative, and health-related roles within UVA.

📋 Description

• Leverage both your clinical background and CDI expertise to evaluate complex inpatient records and ensure documentation accurately reflects patient acuity and care delivery. • Review inpatient medical records for accuracy, completeness, and compliance. • Identify documentation gaps, inconsistencies, and opportunities for clarification. • Issue physician queries to resolve unclear or incomplete documentation. • Partner with interdisciplinary teams, including: Physicians and advanced practice providers, Coding professionals, Quality teams and service lines, Specialty teams such as wound care and nutrition. • Support accurate coding prior to discharge. • Ensure the accuracy and completeness of clinical information, which is used for measuring and reporting physician and hospital outcomes. • Provide education to providers to strengthen documentation practices. • Manage a steady caseload of 15 new cases per day, along with follow-ups and re-reviews.

🎯 Requirements

• RN, graduate of accredited nursing program and Bachelor of Science in Nursing required within 5 years of hire. • A minimum of three years of experience as a Clinical Documentation Specialist is required. Clinical experience in multiple areas, particularly in the ICU, is preferred. • CCDS (Certified Clinical Documentation Specialist), or CDIP (Clinical Documentation Improvement Practitioner) is preferred. • Licensed to Practice as a Registered Nurse in the Commonwealth of Virginia.

🏖️ Benefits

• Comprehensive Benefits Package: Medical, Dental, and Vision Insurance • Paid Time Off, Long-term and Short-term Disability, Retirement Savings • Health Saving Plans, and Flexible Spending Accounts • Certification and education support • Generous Paid Time Off